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.� STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD uy��, e UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B - , I COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY TANK CLOSURE 8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN S A OWNER'S TANK I.D.It :;,A— I B. MANUFACTURED BY: Uk 117- C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: AS WV 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE TEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. C. L-i 1A REGULAR UNLEAD® 3 DIESEL ❑ B AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY "N6 I PRODUCT LJ Ib PREMNM UNLEADED 4 GASAHOL ❑ 7 METHANOL 'K __' ❑ 1e MNGRADE UNLEADED S JET FUEL ❑ B MB5 ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOWI D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORI 1ZC.A S•: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C, ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN SYSTEM IR 2 SINGLE WALL ❑ 4 SINGLE W INA VAULT ❑ 99 OTHER B. TANK okl 1 BARE STEEL ❑ 2STAINLES STEEL ED FIBERGLASS ❑ 4 STEEL CLAD W?FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POL CHLORIDE ❑ 7 ALUMINUM ❑ B 700% METHANOL COMPATIBLE W/FRP (Primary T9nk) ❑ 9 BRONZE ❑ 10 ANIZED STEEL ❑ BS UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE 100% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BN:. SPILL CONTAINME INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO— STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ C IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE ALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A IP9 1 BARE YEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U5 ALU UM A U B CONCRETE A U 7 STEEL W/COATING A U B 1DO% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GA ANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 wCRx LONE IFAI( 2 LONE 1X9Rra:ss IA+E sp ❑ ss oH2R3Mam46 SMRDOWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RMECO CIUATIONORY ❑ 3 VADOZEMONITORING ❑ 4 GAUD NG C TANK ❑5 MON MONITOOUND RING ❑ B TESTING ❑ Ur 7 MONITORINGCONTINUOUS INTERSTITIAL ❑ B SIR ❑ B WEEKLY MANUAL ❑ 10 MONTHLGY TANK ❑ 95 UNKNOWN ❑ 98 OTHER SIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) �4 1.E MESTIMA D QUANTITY OF 3.WAS TANK FILLED WITH YES NO IJt, � ATED DATE LAST USED(MO/DAY/YR) 2.5 SUBS NCE REMAINING GALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENA OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK�WNBR'S NAME.A� LLA IV` 2Y DATEl2.,Z-cj� (PRINTTD651ONANRN J4Kl ��//�� LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY Y JURISDICTION 0 FACILITY M TANK 11 STATE I.D:# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PI-V. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORME (8-95) _ _ / (��2� �/♦�L�